Page 16 - Intertek 2021 Benefits Guide
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Dental
Dental Coverage with Delta Dental
Choose a Delta Dental PPO dentist to ensure you
receive the deepest discounts. Choose a Delta
Premier dentist and receive discounts, although
they may not be as deep as the PPO network. If
you receive care outside of Delta’s PPO or Premier
network you will likely pay a greater amount for
dental care and the provider may balance bill you.
To ind a Delta Dental network provider in your area
go to deltadentalins.com or call 800.521.2651.
Delta Out-of-
Network Network
Deductible/Maximum
Individual deductible $50 $50
Family deductible $150 $150
Calendar year maximum $1,500 $1,500
Coinsurance
Preventive services 100% no 100% no
(Exams, x-rays, cleanings) deductible deductible
Basic services 80% after 80% after
(Fillings, root canals, oral deductible deductible
surgery)
Major services 50% after 50% after
(Bridges, crowns, dentures) deductible deductible
Orthodontia
Coinsurance 50% 50%
Lifetime maximum $1,500 $1,500
Eligibility Dependent children to age
26
Your cost of coverage is summarized when you enroll
online through https://my.adp.com.
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Dental Coverage with Delta Dental
Choose a Delta Dental PPO dentist to ensure you
receive the deepest discounts. Choose a Delta
Premier dentist and receive discounts, although
they may not be as deep as the PPO network. If
you receive care outside of Delta’s PPO or Premier
network you will likely pay a greater amount for
dental care and the provider may balance bill you.
To ind a Delta Dental network provider in your area
go to deltadentalins.com or call 800.521.2651.
Delta Out-of-
Network Network
Deductible/Maximum
Individual deductible $50 $50
Family deductible $150 $150
Calendar year maximum $1,500 $1,500
Coinsurance
Preventive services 100% no 100% no
(Exams, x-rays, cleanings) deductible deductible
Basic services 80% after 80% after
(Fillings, root canals, oral deductible deductible
surgery)
Major services 50% after 50% after
(Bridges, crowns, dentures) deductible deductible
Orthodontia
Coinsurance 50% 50%
Lifetime maximum $1,500 $1,500
Eligibility Dependent children to age
26
Your cost of coverage is summarized when you enroll
online through https://my.adp.com.
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